What is the correct way to start an intravenous (IV) line without the risk of air embolism?

Correct Way to Start IV Line Without Risk of Air Embolism

To prevent air embolism when starting an IV line, place the patient in Trendelenburg position, occlude the catheter hub except during insertion, ensure secure connections between the catheter hub and tubing, and use proper flushing techniques. 1, 2

Preparation and Positioning

• Position the patient in Trendelenburg position (head down) during IV line insertion to increase venous pressure and reduce the risk of air entry 3
• Prepare all necessary equipment in advance and create a sterile field to minimize the time the system is open 2
• Perform proper hand hygiene using either alcohol-based waterless product or soap and water before catheter insertion or manipulation 2

Insertion Technique

• Use ultrasound guidance for catheter insertion when appropriate to reduce complications and improve success rates 2
• Occlude the catheter hub at all times except briefly during insertion to prevent air entry 3
• Apply alcoholic chlorhexidine solution (minimum 2% CHG) to the insertion site and allow it to dry completely before puncturing the skin 2

Connection and Securing

• Ensure secure fixation of the catheter hub to its connections to prevent disconnection, which is the most frequent cause of air embolism 3
• Use Luer-lock connections rather than slip connections to prevent accidental disconnection 2
• Apply a sterile, transparent dressing over the insertion site to secure the catheter 2

IV Fluid Administration

• Inspect IV fluid bags for air before connecting to the IV line 4
• When using pressure bags for rapid infusion, check and remove all air from the IV bag first 4
• Use self-collapsible IV fluid bags with self-sealing outlets when possible, as they have less risk of air entry compared to conventional bottles 4
• PVC-based bags have more flexibility and significantly less risk of air entry when IV administration sets are disconnected from the outlet 4

Maintenance and Monitoring

• Perform routine flushing with saline after completion of any infusion or blood sampling 2
• Replace administration sets and needle-less connectors according to institutional protocols (typically at least every 7 days) 2
• Monitor the IV site regularly for any signs of disconnection or infiltration 2

Recognition and Management of Air Embolism

• Be vigilant for signs of air embolism: sucking sound, tachypnea, air hunger, wheezing, hypotension, and a "mill wheel" murmur 3
• If air embolism is suspected, immediately place the patient on high-flow oxygen 5
• For venous air embolism, position the patient in left lateral decubitus and/or Trendelenburg position 5
• For arterial air embolism, position the patient in right lateral decubitus position 5
• Consider hyperbaric oxygen therapy for significant air embolism as it decreases the size of air emboli and improves tissue oxygenation 5

Special Considerations for High-Risk Procedures

• Take extra precautions during central venous catheter placement and removal, as these procedures carry higher risk of air embolism 6
• When removing central venous catheters, place an occlusive dressing over the track after removal 3
• For patients with pulmonary arteriovenous malformations (PAVMs), take additional precautions as IV contrast material administration adds a small risk of air embolism 7